The Physician Quality Reporting System is a pay-for-performance program that currently applies to Medicare and Medicaid providers, but the idea is catching on in other arenas such as Workers Compensation, according to panelists at the 2015 Workers’ Compensation Educational Conference.
The panelists, including executives from claims management firms and risk funding agencies, discussed the fundamental shift from the "fee schedule discounts" model to a method focused more on outcomes on a per-bill basis. The transition to this type of program follows initiatives in Medicare and Medicaid reimbursement such as the PQRS system, based on standardized measures to track and incentivize patient care.
Measures for quality-based care might include:
- Claim duration
- Return to work
- Recidivism (reopening rate)
- Following established treatment and return-to-work guidelines (ODG)
- Litigation rate
- Medical and indemnity paid
- Claims team surveys
- Billing, pre and post bill review
- Peer comparison
Panelists explored the benefits of a quality-based program with higher reimbursement for physician service that will "easily be recovered in duration and utilization of treatment."
A review of the event by Safety National provides this analysis of quality-based payment networks:
The outcomes from these networks has been very favorable. Data presented from over 147,000 claims in California showed that the cost per claim for a five-star provider was 16 times less than what was delivered by a one-star provider. Average lost time days was 10 times greater with one-star providers versus five-star. Duration of the claim was nine times greater for a one-star versus a five-star.
The PQRS program is currently in effect for Medicare and Medicaid claims, and penalties for non-compliance will be assessed in 2015 and applied in 2017. For more information on this shift in reimbursement programs, JTECH is hosting a webinar next week on the Fundamentals of PQRS.
This developing situation represents a significant shift in reimbursement in the coming months. Let us know how you believe it will affect you in the comments below!